11 Functional Behavioral Assessment Interview Form Name ________________ Information Provider ________________Date___/___/___ Interviewer____________________ Interview method _______________________ How long have you known the person? ______ How often do you currently see the person? ________ How much time did you spend together this past week?_________ What are the person’s favorite things to do? _________________________________ ____________________________________________________________________ How often does she/he get to engage in those activities? _______________________ Who are some of her/his best friends? ______________________________________ How often does she/he get to see these friends?______________________________ Name some individual strengths __________________________________________ ____________________________________________________________________ What activities does she/he currently do that use those strengths?________________ _____________________________________________________________________ What activities might be an opportunity for those strengths? ____________________ ____________________________________________________________________ What forms of communication does she/he use? ____________________________ ____________________________________________________________________ Is special effort or training required by the receiver of the communication? ________ Does she/he have a universally understandable (UU) or an idiosyncratic signal (IS) to communicate the following: Example: Yes. (UU) nods head or says “yes” or (IS) high pitched squeak and hop Yes. ________________________________________________________________ No. _________________________________________________________________ More. _______________________________________________________________ Done. _______________________________________________________________ I want Xxxx. __________________________________________________________ I need Xxxx. __________________________________________________________ Greeting comment. _____________________________________________________ Departing comment. ____________________________________________________ What receptive communication modes does she/he respond to? (verbal, sign language, written words, picture cues, body language, visual schedule) ___________________________ ______________________________________________________________________ 12 Does she/he exhibit any disruptive behaviors? (e.g. screaming/task refusal) List behaviors ___________________________________________________________ ___________________________________________________________________ Does she/he exhibit any destructive behaviors? (e.g., aggression, self-injury, or property destruction) List behaviors _______________________________________ ______________________________________________________________________________________ Are medications taken that effect behavior? ___ How? ________________________ ____________________________________________________________________ Are there sleeping or eating issues that effect behavior? _______________________ ____________________________________________________________________ Are there other medical or physical problems that effect behavior (e.g. allergies/acid reflux/constipation)? ___________________________________________________ ____________________________________________________________________ During which activities does she/he have many problem behaviors? _____________ ____________________________________________________________________ During which activities does she/he have few or no problem behaviors? __________ ____________________________________________________________________ Does she/he show any behaviors that signal a problem behavior is likely to occur? (e.g. loud humming, foot tapping, pacing) __________________________________ ____________________________________________________________________ Does she/he have verbal communication that provides a warning problem behavior may soon occur? ______________________________________________________ How would she/he react to the following situations? Left alone with no preferred items for 15 minutes? ____________________________ ____________________________________________________________________ Left alone with preferred activities? ________________________________________ ____________________________________________________________________ With attention from a non-preferred person? _______________________________ ___________________________________________________________________ The person is required to complete an easy and preferred task? _________________ ____________________________________________________________________ 13 The person is required to complete an easy but non-preferred task? ____________________________________________________________________ ____________________________________________________________________ The person is required to complete a difficult task? ___________________________ ____________________________________________________________________ Would it make a difference in any of the above demand situations if attention/assistance is not available? _______________________________________ A preferred activity has to be discontinued to transition to a less preferred activity? __ ____________________________________________________________________ A preferred item or activity is unavailable? __________________________________ ____________________________________________________________________ A preferred person is unavailable? ________________________________________ ____________________________________________________________________ A setting which contains intense sensory stimulation (e.g., mall, fire drill, class hallways)? _______________________________________________________ List one event that is almost guaranteed to produce severe problem behavior. _____ ____________________________________________________________________ List one event that is almost guaranteed to reduce severe problem behavior. ______ ____________________________________________________________________ Does she/he use a schedule? ___ What type? _______________________________ Is the schedule predictable on a daily basis? _______________________________________ Is a timer used for scheduled activities? ___________________________________________ How many items are typically on the schedule? ____________________________________ Does the schedule include access to preferred activities? _____________________________ Does the schedule include Free Time or Choice Time? ________________________________ What would the perfect setting look like for her/him? _____________________________________________________________________________ _____________________________________________________________________________ What is something you think others should know about her/him? _________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________